Relational Care Intake Form

Relational care intake form

Your healing journey begins here. All information is confidential. Please complete this form to the best of your ability so we can best support you in Case Management and/or Relational Care.
Name*

First NameLast Name
Preferred Name & Pronouns*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Services requested*

Case ManagementRelational CareBoth
Cultural & personal background
Tribal Affiliation / Cultural Identity*
Primary Language*
Please share the spiritual or cultural protocol or practices you'd like to be respected in care:
What brings you to Hummingbird Medicine at this time?
Do you have any immediate needs such as food, housing, safety, emotional support, legal, or other?
What are some long-term goals you hope to work on together?
California legal waiver disclaimer
Hummingbird Medicine Wellness Center is not a licensed mental health clinic.

Our services are designed to provide culturally rooted support, case management, relational care, wellness education, and traditional healing practices. We do not diagnose, treat, or provide clinical psychotherapy as defined under California law.

By submitting this form, you acknowledge that:

• Services provided are not a substitute for licensed medical, psychological, or psychiatric care.

• If you require diagnosis or treatment for a mental health condition, we will provide referrals to licensed professionals.

• Your participation is voluntary, and you may discontinue at any time.

• All information shared will be kept confidential except as required by law (including cases of abuse, danger to self/others, or court orders).
Please sign that you acknowledge and agree to the terms above:*

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Relational care intake form

Cultural & personal background

California legal waiver disclaimer